state of afghanistan’s midwifery 2014

State of Afghanistan’s Midwifery 2014

Delivering a world where every pregnancy is wanted, every childbirth is safe and every young person’s potential is fulfilled

State of Afghanistan’s Midwifery 2014© UNFPA 2014United Nations Population Fund (UNFPA)Country Office AfghanistanThis publication can be downloaded free of charge at: http://afghanistan.unfpa.orgWriter: Fatima RajaDesign: Daniel Feary, Ali MohaqqeqStories: Marzila Mashal and Jessica GoldenPhotography: Rada Akbar / UNFPA Afghanistan 2014

UNFPA, the United Nations Population Fund, is the lead UN agency for delivering a world where every pregnancy is wanted, every birth is safe, and every young person’s potential is fulfilled.

Support for this document was provided by the United States Agency for International Development (USAID) under Cooperative Agreement AID-OAA-A-11-00015. The contents are the responsibility of the Leadership, Management and Project and do not necessarily reflect the views of USAID or the United States Government.

State of Afghanistan’s Midwifery 2014

Table of Contents

Acronyms 4

Foreword 5

Message from the Minister of Public Health 7

Midwives save lives 9

Midwifery in Afghanistan: before 2002 12

Revitalizing midwifery: 2002 to today 14

Midwifery today 17

Afghanistan’s way forward 33

Endnotes 39

3

AMA Afghan Midwives Association

BPHS Basic Package of Health Services

EmONC Emergency obstetrics and newborn care

EPHS Essential Package of Hospital Services

HPP Health Policy Project

ICM International Confederation of Midwives

JHPIEGO John Hopkins Program for International Education in Gynaecology and Obstetrics

MDG Millennium Development Goal

MNH Maternal and newborn health

MSH Management Sciences for Health

OAM Organization of Afghan Midwives

UNFPA United Nations Population Fund

USAID United States Agency for International Development

WHO World Health Organization

Acronyms

4

In July 2014, the United Nations Population Fund (UNFPA), in partnership with the World Health Organization (WHO) and the International Confederation of Midwives (ICM) released the second State of the World’s Midwifery report which reports on 73 low and middle income countries including Afghanistan.

Together, these countries account for more than 92 per cent of the world’s maternal and neonatal deaths, yet have only 42 per cent of its qualified birth attendants — in Afghanistan itself, a woman dies every two hours from causes related to pregnancy. The report points out that midwives can substantially reduce maternal and neonatal mortality.

Based on these findings, The State of the World’s Midwifery 2014 report sets the global agenda for midwifery through Midwifery2030, a policy and planning pathway which strengthens midwife-led models of care through four related domains which, collectively, create the conditions for strong and effective midwifery. These domains are:

AvAilAbility. Skilled personnel are available and able to provide the services necessary for maternal and new-born health.

Accessibility. All essential services are available to women when and where they are needed.

AcceptAbility. Cultural and social needs are taken into account when delivering maternal and neonatal health care.

QuAlity. Midwifery education, regulation and professional associations are strengthened so as to ensure a high quality of care.

Throughout the process of developing The State of the World’s Midwifery 2014 report, Afghanistan played an important role in providing accurate data and reflecting on the country’s experiences. These included responding to a structured questionnaire and the organization of a policy workshop, which was recognized as exemplary in the report itself.

Afghanistan’s midwifery programme has seen significant advances since it was re-established in 2002. Current initiatives include community midwifery education, a renewal of midwifery education to develop a four-year direct entry programme leading to a bachelor’s degree and a pilot bridging programme for existing midwives, both to standards set by the ICM. The Midwives and Nurses Council Strategy Plan (2014–2018) proposes an independent body to regulate midwifery and establish standards of practice, and the Afghan Midwives Association is setting up the Organization for Afghan Midwives to implement capacity development programmes. By working together, both internal and external stakeholders can support these initiatives and ensure that gains in Afghan midwifery are consolidated so the vision of Midwifery2030 can be achieved.

Foreword

Dr Annette Sachs Robertson uNFpA RepReseNtAtive FoR AFghANistAN

Hellay Gharshin ActiNg pResideNt oF the AFghAN Midwives AssociAtioN

Dr Rik Peeperkorn who RepReseNtAtive FoR AFghANistAN

5

This is an exciting time for women’s health in Afghanistan. A decade ago, over 1,600 women were dying of causes related to pregnancy and childbirth for every 100,000 live births, and in Badakhshan Province we faced the highest maternal mortality rate ever recorded: 6,500 mothers of every 100,000 live births did not live to see their children grow.

Today, our maternal mortality rate is 327 deaths per 100,000 live births — still unacceptably high, but showing significant progress. Countless families are spared the devastation of losing a mother in childbirth, and for women bearing a child has become a time of new beginnings, not of fear. In this remarkable achievement we celebrate the role played by Afghanistan’s midwives: the courageous women who left their homes for training and took back the knowledge and skill to preserve the lives of women and newborns.

The contributions of these women, and their counterparts around the world, are to be recognized and celebrated. But, as The State of the World’s Midwifery 2014 makes clear, the job is not yet finished. To reduce maternal and neonatal mortality, we must build and support our system of midwifery.

I thank those who contributed Afghanistan’s unique perspective and experiences for this important report. In addition to the Ministry of Public Health, Ministry of Higher Education and the Afghan Midwives Association (AMA) these include UNFPA, WHO, Kabul Medical University, Aga Khan University, Cordaid, the Swedish Committee for Afghanistan, United States Agency for International Development (USAID) through its Leadership, Management & Governance (LMG) Project and the Health Policy Project (HPP), International Confederation of Midwives (ICM), Health Policy Project (USAID), and John Hopkins Program for International Education in Gynaecology and Obstetrics (JHPIEGO).

I would also like to extend my gratitude to those agencies supporting the implementation of the midwifery programme in Afghanistan: World Bank, European Union, the Government of Japan, the Government of Canada and Aga Khan Development Network and UNICEF.

In this context, I am pleased to present The State of Afghanistan’s Midwifery 2014 report . This is a documentation of our successes and shortcomings in building Afghanistan’s midwifery. It also offers us a starting point for a renewed conversation about the future. Midwives remain a crucial part of the public health system, and as we look to the future, I welcome the ongoing partnerships which are essential to consolidating the gains made thus far.

Message from Dr Suraya Dalil

Minister of Public HealtH GovernMent of tHe islaMic rePublic of afGHanistan

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eveRy dAy, About 800 woMeN woRldwide die due to coMplicAtioNs in pregnancy or childbirth.1 Most of these deaths are preventable, as demonstrated by the fact that 92 per cent of these deaths — and 93 per cent of neonatal deaths — occur in only 73 countries, where resources and infrastructure for maternal health services are weak. Despite accounting for 78 per cent of the world’s births per year, they have only 42 per cent of the world’s skilled birth attendants.2 In Afghanistan, which is amongst these 73 countries only 23 per cent of the estimated need for skilled birth attendance is met by the existing health workforce.3

The main causes of maternal mortality are haemorrhage, eclampsia, obstructed labour, sepsis and unsafe abortion, of which over 83 per cent are preventable with timely interventions and family planning.4 Additionally, many newborn deaths can be prevented with good nutrition and hygiene practices and appropriate postnatal care.

To reduce the incidence of death and illness amongst mothers and children, it is essential that childbirth be attended by skilled attendants,* such as midwives, nurses or doctors, who are proficient in the skills required to provide competent care, and to recognize when referral is needed.5 Skilled birth attendants, such as professional midwives, are thus the central node in the continuum of care, from the

Midwives save lives

* The World Health Organization defines a skilled birth attendant as: an accredited health professional such as a midwife, doctor or nurse who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns. (World Health Organization, 2004).

83 per cent of causes of maternal mortality are preventable.

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home to high-level health facility, required for safe and healthy childbirth.

This is why a sufficient cohort of well-educated midwives is recognized as essential to the achievement of Millennium Development Goal (MDG) 5, improving women’s health, through a reduction in maternal mortality, as well as MDG 4 (child health) through a reduction in newborn mortality.6 Professional midwives are increasingly understood to be the key persons for promoting maternal, newborn child and family health.7

This is also acknowledged in the Midwifery2030 vision that by 2030 every woman of reproductive age will have access to a midwife, as articulated in The State of the World’s Midwifery 2014 report.

Midwifery is an ancient profession all over the world and it is widely understood that well-educated, regulated, well-resourced and supported midwives have a crucial part to play in providing skilled birth attendance, enhance reproductive health, and protect the health of newborns and families for all women, and thus in reducing maternal and newborn mortality. This is achievable at low cost: an evaluation of a community midwifery programme in Bangladesh used the avoidance of caesarean sections as a measure to find that investing in midwives could yield a 16-fold return.8 It is also a demonstrably successful approach: in Afghanistan, the efforts to revive and strengthen midwifery since 2002 have been critical to reducing maternal mortality from over 1,600 to 327 deaths per 100,000 live births.

Who is a midwife?

According to the International Confederation of Midwives, “a midwife is a person who has successfully completed a midwifery education programme that is duly recognized in the country where it is located and that is based on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education; who has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery and use the title ‘midwife’; and who demonstrates competency in the practice of midwifery.”

Source: ICM International Definition of the

Midwife. Available at: http://bit.ly/1v6cQ0D

[PDF]

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Pre-pregnancy Antenatal Birth Post-partum Postnatal

family planning visits

10,953,000routine visits

6,291,000skilled birth attendance

1,085,000routine visits

4,341,000

All women ofreproductive age

Pregnancies × 4 Births × 4 Newborns × 4

1,573,000 pregnancies a year. How many episodes of care?

← Gulsom, community midwife, listens to the heart beat of a baby at the Family Health House in Shiber district, Bamiyan province.

↑ Saleema looks at her newborn baby a day after her delivery at the Cure Maternity Hospital in Kabul.

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the pRoFessioN oF MidwiFeRy iN AFghANistAN begAN iN the eARly twentieth century, when King Amanullah sent 12 women from his own family abroad to be trained in nursing and midwifery. During the years that followed the profession prospered: midwives were recognized and respected health professionals, with the prestige of royal patronage.

However, decades of war after the Soviet invasion of Afghanistan in 1979 brought ruin to the country’s well-established health care system, and devastated the midwifery profession. This became particularly acute in 1996, when the Taliban took control of Afghanistan and barred women from attending school.9 Since tradition and law alike prevented women from seeking health care from men, this effectively meant that they were denied skilled attendance at birth — in 2003, it was reported that under a tenth of births were attended by a skilled provider.10 In 2002 Afghanistan’s maternal mortality ratio — the proportion of women who die of causes related to pregnancy or childbirth — stood at 1,600 per 100,000 live births,11 the second highest in the world at the time. Neonatal mortality was also amongst the highest in the world, at 60 deaths per 1,000 live births.12

Midwifery in Afghanistan: before 2002

In 2002 Afghanistan’s maternal mortality ratio was the second highest in the world at the time.

↑ A newborn baby waits to be delivered to his mother at the Family Health House in Ahangaran district, Bamiyan province.

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Feroza Mushtary Former Acting President of the Afghan Midwives Association, Kabul

Birth of a passion

The story of how I chose to become a midwife is complicated. My father was in Kandahar and we lived in Kabul without an adult male

in our family. One day, when I was 13, a neighbour knocked. When we opened the door, we saw that she was with a woman who was screaming in pain. The woman was in labour and needed to go to the hospital. This was during Taliban rule and women weren’t allowed to go anywhere in public, even to the hospital, without a male escort. They wanted to know if a male from our household could accompany them.

When my mother told them there was no adult male in our house, the pregnant woman sat down on the ground hopelessly. I looked down at her feet and saw that they were covered in blood. I looked into her eyes and saw that they were pleading for help.

I decided that I would dress as a boy and accompany her to the hospital. At first my mother forbade me, but after we argued for fifteen minutes, she agreed to let me go. I sat in the front seat of the taxi, where males usually sit. After we arrived at the hospital, the woman gave birth to a baby boy. I felt very proud; this was the moment that I decided that I wanted to help Afghan women.

After the fall of the Taliban, I studied midwifery and graduated in 2004. Now that I am a midwife with the skills and knowledge required for my profession, I feel strong enough to advocate on the behalf of others. My leadership skills give me the confidence to speak out in public and I do this through my position with the AMA.

The AMA has done a lot to aid the recognition of midwifery in Afghanistan. We have worked with the Ministry of Public Health to gain acknowledgment of our profession, and have worked hard to gain community acceptance. We have worked with stakeholders to establish a regulatory body and council. We have drafted an act which is now awaiting approval from the Ministry of Justice. If it is passed, every practicing midwife will be required to register with the AMA and be properly licensed.

“ After we arrived at the hospital, the woman gave birth to a baby boy. I felt very proud; this was the moment that I decided that I wanted to help Afghan women.

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AFteR the FAll oF the tAlibAN RegiMe, AFghANs weRe coNFRoNted with a collapsed health care system. In 2002, there were only 467 midwives serving the entire country, with substantial variation in their capacity.13 With international aid flowing into the country, however, there was a new opportunity to rebuild health care. This set the stage for two great achievements of the Ministry of Public Health and the international community after the fall of the Taliban: the revitalization of midwifery education as per the standards of the International Confederation of Midwives (ICM), and the establishment of the AMA.

In 2003, the Ministry of Public Health contracted non-governmental organizations to implement a Basic Package of Health Services (BPHS) which provides facility and community-based primary health care. This remains Afghanistan’s primary channel of public sector health services provision, alongside the Essential Package of Hospital Services (EPHS), which provide provincial and regional referrals.

Recognizing the challenge posed by Afghanistan’s alarming maternal and neonatal mortality, the Ministry and its national and international partners decided to focus on strengthening midwives as a cadre of female health providers who were distinct from nurses and dealt exclusively with maternal and neonatal health. In 2003, the Ministry of Public Health identified the need for both conventional midwives

In 2002, there were only 467 midwives serving the entire country, with substantial variation in their capacity.

Revitalizing midwifery: 2002 to today

↑ A community midwife examining a child at the Family Health House in Shiber district, Bamiyan province.

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I think most people struggle for their own benefit and according to their own needs; I always try to do something good for my

fellow beings.

Having worked in midwifery for over a decade, I am no stranger to the need for qualified health care professionals — especially trained midwives.

Because of the civil war in Afghanistan, I was forced to leave my country twice — once during my childhood, and once soon after I was married. The second time, my husband and I fled to Pakistan, where I delivered three babies without the supervision of a doctor or a midwife. It was in Pakistan that I decided to train as a midwife. I faced many problems during my pregnancies and deliveries, until a woman gave me the address of a hospital to seek family planning assistance. I was introduced to a midwife whom everyone called “miss”. I didn’t even know her name, but I was very impressed with the work she did. I wanted to help too. I joined Peshawar’s Al Bader Hospital in 1999, and worked there after I graduated as a midwife in 2001.

We came back to Afghanistan after the fall of the Taliban, and I began working with the International Medical Corps in Takhar Province’s Basic Health Centre Clinic. I received on-the-job training which equipped me to take on more responsibilities. One of the most useful

trainings that I received was the USAID-funded Leadership Development Programme.

Using the lessons I learned during that training, I designed the Capacity Building for Saving Lives Project, which aimed to improve awareness of midwives in key areas (leadership, infection prevention, behaviour change, family planning, and gender issues). I shared my ideas with the Afghan Midwives Association, the Provincial Health Directorate of Takhar, and non-government organizations implementing the Basic Package of Health Services. I developed an action plan and, after some struggle, I found a donor, the Marigold Fund. After receiving funding, the project was able to train 80 midwives in Takhar Province.

I am very proud of what I learned from the midwifery training, and that I used what I’ve learned to help my people. I am looking forward to learning more and building my capacity to help more people in need.

Sharara AmanMidwife, Takhar Province

Laying the foundations of midwifery

“ I was forced to leave my country twice. The second time, my husband and I fled to Pakistan, where I delivered three babies without the supervision of a doctor or a midwife. It was in Pakistan that I decided to train as a midwife.”

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based in hospitals, and community midwives deployed to basic health facilities offering the BPHS with a strong emphasis on outreach. Supported by USAID, the World Bank and the European Commission, the Ministry established two streams of pre-service education programmes to accommodate two sets of needs, for hospital and community-based midwives.

Despite issues with retention, social perceptions of women working and inadequate professional support,14 these pre-service education initiatives proved highly effective. By 2008, the public sector health service population coverage rate was estimated to be 85 per cent.15 A national survey in 2010 found that skilled providers attended 34 per cent of all births, of which midwives provided 20 per cent of the care.16

A crucial factor in this success was the system-wide approach taken by the Ministry of Public Health and its international partners. A need for midwives was generated in communities and recruitment occurred on the basis of deployment plans; the Afghanistan Midwifery Education Accreditation Board helped maintain the quality of education, and in 2005 the AMA was established to support advocacy and in-service education.

Today, Afghanistan is a regional leader in the midwifery profession, and a model for reducing maternal mortality in low-resource post-conflict settings. This is demonstrated by the precipitous decline in pregnancy related mortality ratio to 327 per 100,000 live births in 2010;17 figures which represent a profound impact on countless individuals and families, and Afghan society as a whole.18

Today, Afghanistan is a regional leader in the midwifery profession, and a model for reducing maternal mortality in low-resource post-conflict settings.

↑ Midwife measuring the fundal height to assess the fetus growth.

16

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to Reduce MAteRNAl ANd child MoRtAlity, it is esseNtiAl thAt every mother has access to professional care during pregnancy, during childbirth and for six weeks after birth, which may be best provided through a cohort of educated, accredited midwives. The ICM has identified the three pillars of a strong midwifery profession: a high quality education in midwifery, robust regulation to support the profession and protect the public from unsafe practices, and a strong association through which to protect the rights and responsibilities of midwives.

The State of the World’s Midwifery 2014 provides an evidence base on the current state of midwifery in 73 low and middle income countries and delineates a vision to ensure universal skilled birth attendance by 2030. This builds upon the analysis presented in its predecessor, the State of the World’s Midwifery 2011, which assessed countries, including Afghanistan, in terms of education, regulation and association and gave recommendations on how stakeholders — including government, regulators, training bodies and professional associations — should proceed to strengthen midwifery services.

Midwifery today

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Estimates of maternal mortality, rounded to the nearest 10.

Source: WHO, UNICEF, UNFPA, The World Bank

and the United Nations Population Division. Trends

in maternal mortality: 1990 to 2013. WHO, 2014.

Available at: http://bit.ly/1qUJoJT [PDF]

Trends in maternal mortality in Afghanistan

1400

1200

1000

800

600

400

200

1990 1995 2000 2005 20130

↑ Students at the Community Midwifery School in Kabul, Afghanistan.

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EducationTo cement Afghanistan’s position as a regional leader in developing the midwifery profession — a position achieved only a decade after the end of Taliban rule — it is essential to establish educational standards, delineate prerequisites for students and tutors, and establish a national curriculum and educational regimen. This is only possible through an education policy which establishes an education framework to prepare competent midwives and trained faculty members. Afghanistan is amongst the first countries in the region to develop a cohort of internationally recognized degree-level midwives, with approval now being sought for the establishment of a regulatory body and development of a legal framework.

Until 2011, midwives were educated through two routes: an accelerated two year direct entry programme through the Institute of Health Sciences, and a direct entry community midwifery programme (a two year course since 2011). The two programmes have identical competencies and teach a standardized curriculum with quality regulated by the National Midwifery and Nursing Education Accreditation Board. The Institute of Health Sciences entry route is intended to educate midwives at secondary and tertiary health facilities, often in urban areas, while the community midwife route is for women practicing in rural areas. To encourage retention and deploy midwives where they are most needed, candidates for both programmes (75 per cent of Institute of Health Sciences’ graduates and 90 per cent of community midwife graduates) are designated to a duty station at the time of recruitment.

This has proved to be a successful model in Afghanistan: a retrospective study conducted in 2009 found that 96 per cent of community-nominated midwifery graduates were employed,

Afghanistan is amongst the first countries in the region to develop a cohort of internationally recognized degree-level midwives

Midwifery education

Minimum high-school requirement to start training Grade 10+

Years of study required to qualify (rounded) 2

Standardized curriculum? Year of last update Yes, 2010

Minimum number of supervised births in curriculum 25

Percentage of graduates employed in MNH within one year 95%

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I have worked as a trainer for ten years, since my own graduation. I work with the MOVE Welfare Organization where we are currently

training 36 students from Daikundi Province.

My husband never supported this profession and never thought that his wife would become a midwife someday. What motivated me to become a midwife was the death of my neighbour, who passed away during the delivery of her baby. She left behind six children. The incident shocked me — she could have been saved if there had been a midwife with her. This happened during Taliban rule, and after they left power, I studied midwifery. Today, my husband respects me and my profession. I help my in-laws during their pregnancies and deliveries, and I offer financial support to my family.

I am very lucky that I am part of teaching a new generation of women to become midwives. When I see my students working in the most remote areas of Afghanistan, I feel very proud.

Our role as midwives is to save the lives of mothers and children by any means necessary. Last year, when I took my students to a hospital in Mir Bacha Kot District of Kabul Province, we saw a very disheartening situation. If someone came in with symptoms of HIV, they referred him or her to Kabul for diagnosis. If the patient then tested

Educating new midwivesParween Mushtary Trainer, Community Midwifery Education MOVE Welfare Organization

positive, the hospital refused to provide them with care. The situation was unbelievable.

I couldn’t sleep for a few nights; I was thinking about a solution to this problem. Even though I hadn’t received any formal leadership training, I had leadership skills and knew how to conduct training. I returned to the hospital a week later and conducted a one-day HIV transmission and prevention training for all of the health workers in hospital. Afterwards health workers understood how to behave towards people living with HIV and AIDS, especially those who are pregnant. When we visited the hospital the next month, I saw a significant improvement in the behaviour of doctors and midwives towards HIV-positive patients.

This training was a great success and I am happy that, as a trainer and a midwife, I was able to contribute to making patients’ lives better. I will continue to work for the safety of my country’s mothers until the last moments of my life.

“ My husband never supported this profession and never thought that his wife would become a midwife someday.

What motivated me to become a midwife was the death of my neighbour, who passed away during the delivery of her baby.”

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compared to 82 per cent of those admitted through a university entrance exam and 74 per cent of those selected by the Institute of Health Sciences, with no detriment to practical performance despite having less than 12 years of schooling.19

When the community midwifery education programme was extended to two years in 2011, seven new modules were added to develop additional competencies as per ICM standards, including content which provides the skills needed in small clinics where the midwife may be the only health provider. Entry into this programme is dependent upon nomination by communities to help ensure community based midwives are supported in their work and reliably return to work in their home communities.

In 2010 there were 32 midwifery schools around the country, however, in 2013 the number of schools had dropped to 22 due to lack of funding.20 Through the new System Enhancement for Health Action in Transition Programme, the number of midwifery schools is planned to increase to 31 by 2018. To date, the two programmes have educated 4,600 midwives, who have been instrumental in reducing Afghanistan’s maternal mortality ratio.

An evaluation published in 2013 found that satisfaction with the educational programme was high amongst midwives, though many reported that the low threshold for prior education (nine years of schooling) hampered learning.21 An assessment of factors affecting retention rates for community midwives in public sector health facilities found that the pre-service education programmes were not of uniform quality, particularly in terms of access to practical work and the quality of instruction — there is no rigorous monitoring and supervision regimen for trainers.22 Additionally, because Afghanistan started with a severe shortage of midwifery teachers, many fresh graduates were channelled directly into teaching, and had insufficient opportunity to practice their skills outside the classroom.23 This has contributed to relatively poor rates of retention in public health facilities especially in urban areas.24

In 2011, the State of the World’s Midwifery recognized the major advances made since 2002, but acknowledged the need for programmes to evolve including , for example, a four-year graduate course in midwifery, and a bridging programme building on existing two-year programmes.25

To address concerns about retention and following strenuous advocacy by the AMA, the National Policy and Strategy for Nursing and Midwifery Services (2011–2015) identified a need to strengthen direct entry midwifery education in alignment with international standards, and to develop a bridging programme to build the capacity of existing midwives for entry into a single, professionalized cadre.

Through the new System Enhancement for Health Action in Transition Programme, the number of midwifery schools is planned to increase to 31 by 2018.

21

With support from the Ministry of Higher Education, this has led to the development of a new four year direct entry programme intended for students without prior professional credentials and provides a full course of education which produce skilled and competent midwives with bachelor degrees, and is designed according to international standards. It was launched in 2014 and offered by the Faculty of Nursing and Midwifery at Kabul Medical University, which designed it in accordance with the Global Standards for Midwifery Education developed by the ICM. This is the first direct entry midwifery degree programme in South Asia.

Students are admitted to the midwifery programme on the basis of a complete course of secondary education (12 years of schooling) and a national university entrance examination. The programme will be taught by three teachers with bachelor degrees in midwifery science, and one with a masters degree in midwifery education. There is an identified need for teachers who are at least one academic level above their students; 26 to ensure this, faculty members deployed to the programme are trained overseas and are regularly assessed on competency. A clinical site has been designated where clinical midwives supervise students.

To help existing practitioners reach international standards alongside newly qualified midwives, the Ministry of Higher Education has supported the development of a pilot two year Midwifery Bridging

↑ Mother and newborn at Malalai Maternity Hospital.

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Amina Sultani and Masuma Hakimi teacHers in tHe Midwifery bacHelor deGree ProGraMMe, kabul Medical universityWe were born in Iran as refugees. Our families left Afghanistan 35 years ago during the Soviet occupation. After we finished our education we moved back to serve Afghanistan.

When we first moved to Afghanistan we worked as midwives in different capacities but not at a university. We heard about the recruitment process at Kabul Medical University and applied. It was essential to have a midwifery bachelor degree and we both did. We had to pass an exam and present our work to a panel. It was a difficult process, but we were selected.

We are proud of being part of this new initiative led by the Ministry of Higher Education and Kabul Medical University. Maternal mortality and morbidity rates in the country are high and there is a need to improve the quality of care.

Currently Afghanistan has around 4,000 midwives who have passed two years of education. With this bachelor degree, they now have the opportunity to increase their knowledge so they upgrade their skills.

AroyaMidwifery bacHelor deGree ProGraMMe student, kabul Medical universityMy first days at university were challenging. The way of teaching is different from high school. I am enjoying my time here and I really like the environment and my studies. My family always encouraged me to study; they wanted me to become a doctor, but I want to become a midwifery teacher once I finish my bachelor degree.

NasrinMidwifery bacHelor deGree ProGraMMe student, kabul Medical universityIt is because of my family that I am here. Especially because of my father, he really encouraged me to study. I am very grateful to my family.

Although they wanted me to study medicine, I chose to be a midwife. I chose to help Afghan women, because they really need us. Afghanistan needs many changes in many areas. When it comes to health care, I will do whatever I can for women and children.

YaldaMidwifery bacHelor deGree ProGraMMe student, kabul Medical universityKnowledge and tradition are the key barriers for women accessing reproductive health services. For instance, mothers-in-law will say that they delivered their babies at home and that they didn’t need to go to hospital. They will ask their daughters-in-law why they want to go to a hospital.

I have witnessed the difficulties women face in safely de-livering babies. When my cousin was pregnant we called the ambulance but it didn’t arrive on time. She started bleeding and her child died. Happily she survived.

I am from Faryab province. This is the first time I have left my home and family. Once I finish, I want to move back to Faryab. There are a lot of midwives with diplomas there, but no-one with a bachelor degree. I will be the first in my province.

Nurturing a new generation of midwives

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Programme at Zawul Institute of Higher Education, a private institution in Kabul established in 2012. The Bridging Programme is intended for existing midwives to improve their education at the bachelor level, and thus refresh their skills and gain credibility as professionals in their field.

The first intake of students is planned for 2014. The midwifery department can accommodate 50 students, and clinical sites have been identified at major Kabul hospitals. After the pilot, the programme will be duplicated at other universities, and Zawul Institute of Higher Education will become a centre of excellence for training and research.

RegulationAs with all health care, where lives and wellbeing are at stake, appropriate legislation and regulation are vital to protect both midwives and the public they serve. It protects the public, including the most vulnerable, by ensuring that care is of high standard and comes from competent providers who are registered and accountable to a central authority. Critically, legislation and regulation also supports midwives by enabling them to work autonomously in a supportive professional environment, and be acknowledged as health care professionals. This includes the establishment of a recognized regulatory body which sets standards for practice and ethics, registers midwives, and applies sanctions for misconduct. It also includes accrediting education providers and ensuring that ‘midwife’ is a protected title with a recognized definition and scope of practice.

In 2011, The State of the World’s Midwifery identified several gaps in regulation, of which one was the lack of a recognized definition of ‘midwife’. By the time the 2014 report was released, this gap had been closed and ‘midwifery’ now has an official definition which aids in delineating the roles and responsibilities of midwives, and prevents women who have not undergone the appropriate training from being identified as midwives.

Regulation has been described as ‘the missing pillar for midwifery in Afghanistan’. Sustained high quality care occurs in an environment where there is a strong referral network, profession mentoring and the opportunity for continued professional development. With many midwives solely responsible for lifesaving interventions, and working in remote areas where referral systems are weak, the lack of a regulatory system is a cause for concern.

With many midwives solely responsible for lifesaving interventions, and working in remote areas where referral systems are weak, the lack of a regulatory system is a cause for concern.

Next step will be to strengthen regulation in Afghanistan.

→ Community midwife informing about family planning methods to one of her clients at the Family Health House in Bamiyan province.

24

Midwifery regulation

Legislation exists recognizing midwifery as an

autonomous profession

No

A recognized definition of a professional midwife exists Yes

A government body regulates midwifery practice Yes

A licence is required to practise midwifery No

Number of emergency obstetrics and newborn care basic

signal functions that midwives are allowed to practise (out

of a possible 7)

7

Midwives allowed to provide injectable contraceptives/

intrauterine devices

Yes/

Yes

Functions of a midwifery regulatory mechanism

The International Confederation of Midwives has proposed the following global standards for regulation:

• Setting the scope of practice;• Pre-registration education;• Registration;• Relicensing and continuing

competence;• Complaints and discipline; and• Codes of conduct and ethics.

Source: ICM Global Standards for Midwifery Regulation

(2011). Available at: http://bit.ly/1qfcUEq [PDF]

25

I never wanted to become a midwife — I always wanted to become a politician. My father told me that it wasn’t realistic for

a woman to work in politics in Afghanistan. With his encouragement and help, I unwillingly studied midwifery at the Ghazanfar Institute of Health Sciences. After I graduated in 2007, I joined the Indira Gandhi Hospital as a nurse. In 2008 I started working at CURE Hospital, Kabul.

Despite my reluctant start as a midwife, I am now very happy with the work that I do. I am currently the Head of Midwifery at my hospital and the Provincial Director of the Afghan Midwives Association in Kabul. I supervise 26 midwives and two midwife supervisors. Together, we manage 250 deliveries and 600 antenatal care visits each month.

I think that the training I have received during my time with CURE Hospital has given me a sense of pride and respect for the midwifery profession. I am most proud of the USAID-funded leadership training I received in 2012. I noticed a significant change in my life after completing it. Before, I was very emotional; I didn’t listen to my supervisees’

problems to find out possible causes and solutions. Now, I am like a friend to them and they respect me much more than they did before.

Since becoming a midwife and receiving training, everything in my life has changed for the better. I am now a role model for family, friends, and colleagues. I am now able to apply the skills I learned from leadership trainings and from working as a midwife to improve patient care. CURE Hospital has a behavioural health treatment programme, and I use these skills to build relationships between patients, their families, and health workers within this programme.

In the past, the community thought very negatively of the midwifery profession. Many patients and their families didn’t trust us and wanted doctors even for routine procedures. Now, the situation has changed. With the professionalization of midwifery, people trust midwives and respect us as health professionals.

A respected professionFahima Naziri Head of Midwifery, CURE Hospital, Kabul

“ With the professionalization of midwifery, people trust midwives and respect us as health

professionals.”

26

This was acknowledged in the National Policy and Strategy for Nursing and Midwifery Services (2011–2015) which is implemented by academics, non-government organizations, professional organizations (including the AMA) and UN agencies working in collaboration with the government.

The policy identified the acute need for a licensing body for midwives, as well as nurses, and underpinned the development of the Midwives and Nurses Council Strategy Plan (2014–2018) by the Nursing and Midwifery Department under the leadership of General Director of Curative Medicine (Ministry of Public Health) working with the AMA and UNFPA.

Informed by the National Policy and Strategy for Nursing and Midwifery Services 2011–2015, the Afghanistan Midwives and Nurses Council Act, and the Global Standards for Midwifery Education and Regulation of the ICM, this strategy plan sets out the parameters for a Midwives and Nurses Council as a statutory body within the institutional framework of the Ministry of Public Health. It is anticipated to be established and fully functional by 2017.

The role of the Midwives and Nurses Council is to ensure that the health and safety of the general public are protected by regulating the professions and that midwives and nurses are fit to practice, and can autonomously function in an enabling environment, and thus contribute to maintaining the quality of midwifery and nursing for all users in Afghanistan, whether they live in rural or in urban areas.

Professional associationsProfessional associations are recognized by the ICM as vital partners in developing midwives into a dynamic, collaborative and effective team of professionals. A strong non-profit professional association is required to both protect women’s health and rights, and the rights of midwifery practitioners, and to contribute to a better health system through lobbying and increasing awareness.

Midwives’ associations are responsible for continued professional development of their members and providing advice on quality standards. Associations can represent the views and expertise of their members to government on issues and policies related to maternal and neonatal health care, as well as negotiate work or salary. In the event of misconduct, associations may be responsible for advising or representing their members.

Mandate of the Midwives and Nurses Council

The Council shall ensure that midwives and nurses have appropriate standards of practice and are regulated to practice their full set of competencies as defined by the World Health Organization, the International Confederation of Midwives and the International Confederation of Nurses, with the view to protect the public from unsafe practices, ensure quality of services, foster the development of the professions, accountability, identity and status of midwives and nurses.

27

I have been a midwife since 2006, but my exposure to midwifery began before I ever completed my training. I was in the 11th

grade when I went to Malalai Hospital with my mother; she was in labour and needed to deliver her baby. We were at the hospital for a day and a night. Whilst there, I watched the midwives work tirelessly to help the women in their care. It was witnessing their hard work that inspired me to choose this as my profession.

I was a mother of three when I decided to become a midwife. I was very excited, but during my second semester I became unhappy with the behaviour of health workers towards clients. I started regretting having selected this profession but decided to finish my education. In the third semester, I encountered a shocking episode. A young mother was pregnant with her third child but suffered from severe pre-eclampsia. At 2pm we were scheduled to inject MgSO4 but the health worker injected it too fast and the mother went

Leadership for changeMursal MosawiExecutive Director Afghan Midwives Association Kabul

“ I remember the first meeting I attended at the Ministry of

Public Health; I couldn’t speak because I was so shy. Now, I can speak in my own voice. I understand how to lead.”

into cardiac arrest. The health worker called for help but they could not save the mother’s life.

I promised myself to be very kind to patients, and to build the skills required for my profession. There is no regulatory body in Afghanistan which protects women and families by ensuring that safe and competent midwives provide high standards of care. I was very disappointed with the way health care workers interacted with patients.

However, the words of Pashtoon Azfar encouraged me and gave me hope. Leadership and management training has also given me hope and supported my career development. All areas of my life — social, economic, individual, family, and academic — have been positively impacted by my work, and I am convinced that the profession can bring important changes to communities, empower women and save the lives of mothers and babies.

I remember the first meeting I attended at the Ministry of Public Health; I couldn’t speak because I was so shy. Now, I can speak in my own voice. I can replicate the voices of other women to be heard by policy makers. I can act as Executive Director of the AMA and OAM. I understand how to lead. I am now proud to be called “midwife”.

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The AMA’s mission

The midwifery profession shall be recognized as an autonomous and distinct profession in the country.

The AMA works to strengthen the capacity of midwives and advocate for work and policy conducive environment so that midwives can provide high quality midwifery services according to the ICM code of ethics and core competencies to women, newborns and families in Afghanistan.

Professional associations

Year of creation of professional associations 2005

Roles performed by professional associations

Continuing professional development Yes

Advising or representing members accused of misconduct No

Advising members on quality standards for maternal and newborn health Yes

Advising the Government on policy documents related to maternal and

newborn health

Yes

Negotiating work or salary issues with the Government Yes

In Afghanistan, the recognized association performing this role is the AMA. The AMA was established with financial support from USAID and technical support from JHPIEGO in May 2005 with 80 members. In November 2005, it became a full-fledged member of the ICM. It seeks to:

• Advocate for and within the midwifery profession;

• Build partnerships to support women’s health and empowerment;

• Gain national recognition as the technical body for midwifery edu-cation, providing support to pre-service programmes, and ensuring that Afghan midwives achieve the highest quality standards;

• Work towards the establishment of a Midwives and Nurses Council to better regulate the profession;

• Ensure that the AMA and its business affiliate, the Organization for Afghan Midwives, are sustainable.

Today, a decade after its foundation, it has grown to over 3,000 practicing midwives and students, with a chapter in every province of Afghanistan. It is a major partner, along with the Government of Afghanistan, the Ministry of Public Health, and local and international partners such as UNFPA and WHO, in the joint effort to achieve the MDGs relating to maternal health, child mortality, and gender equality and is registered with the ministries of Justice, Public Health and Women Affairs for its safe motherhood activities and women empowerment initiatives. The AMA is the technical lead for

29

I realized that my country is really in need of this profession, and I stepped forward to be one who fulfils this need.

I work at Sama Hospital, where I am a Technical Advisor, Head of Nursing, and also work in the Anaesthesiology Department. I am one of ten midwives who work at the hospital. The largest portion of my work is assisting women in labour and delivery.

I believe my role as a midwife impacts service delivery in many ways. For example, I was on duty last year during Eid al-Fitr when a man brought his wife into the hospital. Her baby was stillborn and she was in a state of shock. She had lost a lot of blood on her way to the hospital; we gave her a blood transfusion but she needed more because she was bleeding heavily. There wasn’t a doctor on duty at the hospital because it was a public holiday, so it was up to me to figure out how to help her. I didn’t lose confidence. I found a way to give her additional blood transfusions and stop the bleeding and she lived. I am really proud and thankful whenever I think of this case.

Women also come to our hospital for advice; they trust our guidance. Midwives are well-respected in our community; this is different from how it was in the past. I believe that this level of respect is the result of having trained midwives who are able to behave professionally and communicate well with their patients. When midwives are properly trained, they can offer cost-effective and quality services to the community. This is important because we serve the most important creatures on earth: mothers.

I never feel isolated from other clinical professions. We are all wheels on the same car; we cannot work separately to help those most in need in our community. When we all work together, more lives can be saved and midwives can continue to increase their responsibilities.

On the frontlines of careHelay GharshinVice-President of the Afghan Midwives Association Kabul

“ I never feel isolated from other clinical professions. We are all wheels on the same car; we cannot work separately to help those most in need in our community.”

30

midwifery education, professional development and policies which help midwives offer the highest level of care to Afghan mothers and children, and play a role in all policy discussion relating to the midwifery profession. Since 2011, the AMA has led the push to establish the Afghanistan Midwives and Nurses Council.

The AMA has celebrated significant achievements since its foundation. AMA advocacy was critical in the Ministry of Higher Education’s decision to develop Afghanistan’s first four-year degree midwifery programme and the two-year bridging degree programme. The AMA is a technical partner in implementing the latter, with the Zawul Institute of Higher Education.

As a member of the ICM, the AMA is an active participant in global conversations on midwifery and maternal mortality, and brought the views and voices of Afghan midwives to international debates by organizing two national workshops in January 2014 which identified national challenges and solutions to feed into The State of the World’s Midwifery 2014 report.

In 2012, the AMA formed the Organization for Afghan Midwives (OAM). This is the business affiliate of the AMA, and is presently transitioning from being entirely volunteer-run to become a self-managed organization. It implements programmes to enhance capacity and provide professional development to midwives, and thereby increase access to quality services for women and newborns across Afghanistan.

↑ Midwife caring for newborn at Malalai Maternity Hospital, Kabul. ©UNAMA/Jawad Jalali

31

woRkFoRce AvAilAbility, 2012

estiMAted Met Need FiNANciAl Accessibility

Midwives

Physicians generalists

Obstetricians and gynaecologists

3500 100%

100%

12%

Time spent on maternal and newborn healthNumber of staff working in maternal and newborn health

4200

400

Percentage of 46 reproductive, maternal and newborn

essential interventions included in minimum health

benefits package, 2012

Estimate of met need (national aggregate)

based on available data.

17%Not coveredn=8

23%

83%Coveredn=38

Workforce time availableEstimated met need =

Workforce time needed

32

to Achieve the visioN oF MidwiFeRy 2030 As ARticulAted iN the State of the World’s Midwifery 2014, it is essential that professional trained midwives be available: to provide the services needed by women and newborns. This also entails that educated women have the incentive to remain and grow as midwives; that they are recognized and celebrated as critical health professionals in their own right. Their services should be accessible: midwifery services should be affordable and planned so that midwives are encouraged to serve where they are most needed. Midwives should provide quality care: they should be educated and regulated to a high standard, and organized through professional organizations which contribute to national debates on public health.

Afghanistan has made impressive progress in the decade since the revitalization of the midwifery profession. Now, however, is the time to consolidate these gains and bring professional midwives to every woman by advocating for action in the four domains identified above.

Advocating for availability The need for sexual and reproductive health, family planning and maternal and neonatal health care services to accommodate Afghanistan’s population may be assessed through the working time

Midwives should provide quality care: they should be educated and regulated to a high standard, and organized through professional organizations which contribute to national debates on public health.

Afghanistan’s way forward

33

2030

2030

2025

2025

2020

2020

2015

2015

2013

2012

3300

3300

4400

2200

2200

1100

1100

pRojected iNFlows

pRojected woRkFoRce

20302025202020152012

3300

4400

2200

1100

pRojected

4400 maternal and newborn health workers full-time equivalent

key

Outflow from attrition,

death and retirement

Medical practitioners,

specialists (Ob/Gyn)

Medical practitioners,

generalists

Midwifery professionals

34

health care staff devotes to providing these services — for instance, a midwife devotes 100 per cent of her time to these services, whilst physicians devote 12 per cent of their time. At present, availability of services is low: in 2012, only 23 per cent of estimated service need was met. If Afghanistan maintains its current graduation rate for providers of these services, only 8 per cent of estimated service need will be met in 2030. Even if graduation rates are doubled, efficiency improved and retention doubled, however, it is projected that only 31 per cent of estimated need will be met in 2030.

Thus there is an urgent need to strengthen health services by advocating for:

• increasing the number and efficiency of educated professional midwives who spend 100 per cent of their time on sexual, reproductive and maternal health care;

• improving recruitment policies to ensure that sufficient numbers of students who will continue practicing are inducted;

• improving career pathways to render this an attractive option for young women;

In 2012, only 23 per cent of estimated need was met, and if Afghanistan maintains its current graduation rate, only 8 per cent of estimated need will be met in 2030.

↑ Midwife with mother and newborn. ©UNFPA Afghanistan

35

sceNARio 2: If the efficiency of services provided increases by 2% annually till 2030, then met need in 2030 is 12%

sceNARio 1: If the number of midwives, nurses and physicians to graduate doubles by 2020, then met need in 2030 is 14%

sceNARio 3: If attrition is halved in 2012–17, then met need in 2030 is 12%

if all tHree of tHese scenarios occur, tHen Met need in 2030 is 31%

8% Met need

2030

8% Met need

2030

8% Met need

2030

14% Met need

2030

12% Met need

2030

12% Met need

2030

Met need for maternal and neonatal health care in Afghanistan

In 2012, 23% of the estimated need for workforce time spent on maternal and neonatal health was met.

↑ Community midwife examining one of her clients at the Family Health House in Shiber district, Bamiyan province.

36

• improving retention policies through on-going support for the profession, including incentives and improved salaries, continued education, and family support, especially for women in conservative rural areas;

• strengthening community engagement to retain midwives in conservative rural areas.

Advocating for accessibilityAccessibility of midwifery coverage means that women, no matter their location or socio-economic background, receive midwifery and other health services when they are needed. This entails specifically targeting under-served communities for service provision. In Afghanistan, the community-based midwife programme has contributed to increasing the proportion of the Afghan population within a two-hour walk of the nearest basic health services from 9 per cent when the BPHS was introduced to 85 per cent six years later.27 A 2011 evaluation found that whilst user satisfaction was high, many rural communities indicated shortfalls in access, including lack of transportation, insecurity, too few midwives, and short hours of operation.28

It is also important that health services are financially accessible. The State of the World’s Midwifery 2014 recommends that 46 essential services be provided free of charge, of which 38 are covered in Afghanistan.

To improve accessibility in Afghanistan, advocacy focuses on:

• providing the remaining eight essential services free of charge;

• improving recruitment and retention of midwives, especially in rural areas.

Advocating for acceptabilityFor midwifery services to contribute to the reduction of maternal and neonatal mortality, they must first of all be acceptable to service users. This implies health services whose workers win the respect of service users and promote demand. It also means that health services as a whole respect medical ethics and are culturally sensitive. The development and enforcement of policies on safe practice, medical ethics and respectful care are essential for this. With the introduction of the White Ribbon Alliance in partnership with the AMA in Afghanistan, the former’s Respectful Maternity Care focus will prove an important channel for raising awareness.

In Afghanistan, the community-based midwife programme has contributed to increasing the proportion of the Afghan population within a two-hour walk of the nearest basic health services from 9 per cent when the BPHS was introduced to 85 per cent six years later.

37

Acceptability is a critical concern in Afghanistan, however the nature of midwifery as a woman-oriented service means that it can be more acceptable even in conservative communities, and contribute towards easing traditional restrictions on women’s mobility.29

To improve the acceptability of the midwifery profession in Afghanistan requires further advocacy on:

• the development of policy on acceptable safe practices;

• improved implementation of the Nursing and Midwifery Policy and timely establishment of the Midwives and Nurses Council;

• improved working environment for midwives;

• the incorporation of modules on respectful care into midwifery education.

Advocating for qualityPoor service quality can undercut gains made in any other aspect of service provision. The three pillars of midwifery quality are education, regulation, and association.

Education is strengthened by developing robust education consistent with international norms and delivered by trained faculty members, as the new direct entry and bridging programmes seek to achieve in alignment with ICM Global Standards.

Quality standards are maintained on the basis of regulation which protects midwifery as a profession and maintains standards of care. As such, there is a need in Afghanistan to improve regulation through a strong and well-supported Afghanistan Midwives and Nurses Council, to be established by 2017. This will enable a clear and official definition of midwifery competencies, and will also enable licensing procedures which require and facilitate continued professional development.

A strong professional association of midwives can and should play an important part in advising the government on policy related to maternal and neonatal health, and to represent midwives’ interests to government and others, and to participate in regional and global networking through the ICM, the White Ribbon Alliance and other communities of practice. Afghanistan benefits from the strong and active AMA, which recently successfully advocated for the introduction of degree level midwifery training.

38

1 WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division,

Trends in Maternal Mortality: 1990 to 2013 (Geneva: 2014), http://apps.who.int/iris/bitstream/10665/112682/2/9789241507226_eng.pdf.

2 For a full list of these countries and the source for the figures cited, please see UNFPA, ICM and WHO, The State of the World’s Midwifery 2014 (New York: UNFPA, 2014), http://unfpa.org/public/home/publications/pid/17601.

3 Ibid.

4 Caroline SE Homer, Ingrid K Friberg, Marcos Augusto Bastos Dias, Petra ten Hoope-Bender, Jane Sandall, Anna Maria Speciale, Linda A Bartlett, ‘The Projected Effect of Scaling Up Midwifery’ The Lancet (348) 2014, doi: 10.1016/S0140-6736(14)60790-X.

5 International Family Care. ‘Skilled Care During Childbirth: Country Profiles’, (New York: Family Care International, 2002), http://www.familycareintl.org/UserFiles/File/Skilled%20Care%20Info%20Kit%20PDFs/English/Information%20Booklet_English.pdf.

6 WHO, ‘Making Pregnancy Safer — The Critical Role of the Skilled Attendant: A Joint Statement by WHO, ICM and FIGO’, (Geneva: WHO, 2004).

7 Véronique Filippi, Carine Ronsmans, Oona MR Campbell, Wendy J Graham, Anne Mills, Jo Borghi, Marjorie Koblinsky, David Osrin, ‘Maternal Health in Poor Countries: The Broader Context and a Call for Action.’ The Lancet (368) 2006, doi: 10.1016/S0140-6736(06)69384-7.

8 UNFPA, ICM and WHO, The State of the World’s Midwifery 2014 (New York: 2014) http://unfpa.org/public/home/publications/pid/17601.

9 Paula L Herberg, ‘Nursing, Midwifery and Allied Health Education Programmes in Afghanistan’, International Nursing Review 52 (2005), 123–133.

10 Ministry of Public Health, ‘Afghanistan Multiple Indicator Cluster Survey 2003: Report to the Afghanistan Ministry of Public Health by the Johns Hopkins University Bloomberg School of Public Health & Indian Institute of Health Management Research’, (unpublished, 2003).

11 Linda A Bartlett, Shairose Mawji, Sara Whitehead, Chadd Crouse, Suraya Dalil, Denisa Ionete, Peter Salama, ‘Where Giving Birth is a Forecast of Death: Maternal Mortality in Four Districts of Afghanistan, 1999–2002’, The Lancet 365 (2005), doi: 10.1016/S0140-6736(05)71044-8.

12 Joy E Lawn, Simon Cousens, Jelka Zupan, for the Lancet Neonatal Survival Steering Team, ‘Four Million Neonatal Deaths: When? Where? Why?’ The Lancet 365 (2005), doi: 10.1016/S0140-6736(05)71048-5.

13 Ministry of Public Health. Afghanistan National Health Resources Assessment December 2002, (Kabul: Ministry of Public Health, 2003).

14 Molly E Wood, G Farooq Mansoor, Pashton Hashemy, Emily Namey, Fatima Gohar, Saadia Fayeq Ayoubi, Catherine S Todd, ‘Factors Influencing the Retention of Midwives in the Public Sector in Afghanistan: A Qualitative Assessment of Midwives in Eight Provinces’, Midwifery 29 (2013), doi: 10.1016/j.midw.2013.07.004.

Endnotes

39

15 Ministry of Public Health, Afghanistan. A Basic Package of Health Services for Afghanistan – 2010/1389, (Kabul: Ministry of Public Health, 2010).

16 Afghanistan Public Health Institute, Ministry of Public Health, Central Statistics Organization, ICF Macro, Indian Institute of Health Management Research, WHO/EMRO, Afghanistan Mortality Survey 2010, Calverton, Maryland, USA: APHI/MoPH, CSO, ICF Macro, IIHMR and WHO/EMRO, 2011, http://dhsprogram.com/pubs/pdf/FR248/FR248.pdf.

17 Ibid.

18 World Health Organization, in 2013, estimated the maternal mortality ratio at 400 maternal deaths per 100,000 live births.

19 Ghulam Farooq Mansoor, Peter S Hill, Peter Barss, ‘Midwifery Training in Post-Conflict Afghanistan: Tensions between Educational Standards and Rural Community Needs’, Health Policy and Planning 27 (2011), doi: 10.1093/heapol/czr005.

20 Sabera Turkmani, Sheena Currie, Jaime Mungia, Nassim Assefi, Ahmed Javed Rahmanzai, Pashtun Azfar, Linda Bartlett, ‘“Midwives are the Backbone of our Health System”: Lessons from Afghanistan to Guide Expansion of Midwifery in Challenging Settings’, Midwifery (2013), doi: 10.1016/j.midw.2013.06.015.

21 Ibid.


23 Sabera Turkmani, Sheena Currie, Jaime Mungia, Nassim Assefi, Ahmed Javed Rahmanzai, Pashtun Azfar, Linda Bartlett, ‘“Midwives are the Backbone of our Health System”: Lessons from Afghanistan to Guide Expansion of Midwifery in Challenging Settings’, Midwifery 29 (2013), doi: 10.1016/j.midw.2013.06.015.


25 UNFPA, The State of the World’s Midwifery 2011 (New York: UNFPA, 2011).

26 Malin Upper Bogren, Anita Wiseman‘Midwifery Education, Regulation and Association in Six South Asian Countries – A Descriptive Report’, Sexual & Reproductive Healthcare 3 (2012), doi: 10.1016/j.srhc.2012.03.004.

27 John Acerra, Kara Iskyan, Zubair A Qureshi, Rahul K Sharma, ‘Rebuilding the Health Care System in Afghanistan: An Overview of Primary Care and Emergency Services’, International Journal of Emergency Medicine 2 (2009), doi: 10.1007/s12245-009-0106-y.

28 Sabera Turkmani, Sheena Currie, Jaime Mungia, Nassim Assefi, Ahmed Javed Rahmanzai, Pashtun Azfar, Linda Bartlett, ‘“Midwives are the Backbone of our Health System”: Lessons from Afghanistan to Guide Expansion of Midwifery in Challenging Settings’, Midwifery 29 (2013), doi: 10.1016/j.midw.2013.06.015.

29 Ibid.

40

state of afghanistan’s midwifery 2014

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